Paraesophageal Hiatal Hernia

September 14, 2005
Alex J. Mechaber, MD

,
Daniel Gozzi, MD

A 97-year-old woman with a history of hypertension and a paraesophageal hiatal hernia presented with abdominal distention and shortness of breath. Three days earlier, she had fallen and sustained a hairline pelvic fracture; she was evaluated in the emergency department and given narcotics for the pain. Subsequently, the patient's abdomen became increasingly distended, and she had no bowel movement for 3 days.

A 97-year-old woman with a history of hypertension and a paraesophageal hiatal hernia presented with abdominal distention and shortness of breath. Three days earlier, she had fallen and sustained a hairline pelvic fracture; she was evaluated in the emergency department and given narcotics for the pain. Subsequently, the patient's abdomen became increasingly distended, and she had no bowel movement for 3 days.

On admission, report Drs Alex J. Mechaber and Daniel Gozzi of Washington, DC, the woman was in atrial fibrillation with a heart rate of 120 beats per minute and had a markedly distended abdomen. Abdominal radiographs showed diffuse colonic and cecal dilatation, and a chest film, pictured here, revealed a large paraesophageal hiatal hernia illustrated as “air within the cardiac silhouette.” Ogilvie's syndrome was diagnosed; decompression was accomplished with insertion of a nasogastric tube and a sigmoidoscopy. Diltiazem was given for ventricular rate control, and the patient's dyspnea resolved completely.

The patient's condition improved following decompression, and she refused surgical repair of the hiatal hernia. Her hospital stay was complicated only by paroxysms of atrial fibrillation, which were controlled with diltiazem. The patient was discharged from the hospital in stable condition.